Provider Demographics
NPI:1720045685
Name:MCILWAIN, MARK RAY (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAY
Last Name:MCILWAIN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 ASHE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-1729
Mailing Address - Country:US
Mailing Address - Phone:256-383-1499
Mailing Address - Fax:256-383-9135
Practice Address - Street 1:398 ASHE BLVD
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-1729
Practice Address - Country:US
Practice Address - Phone:256-383-1499
Practice Address - Fax:256-383-9135
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO37831223S0112X
AL00016147204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL36801Medicare UPIN